very difficult case. The codes I came up with 44146 and 58720
POSTOPERATIVE DIAGNOSES:
1. Perforated diverticulitis with large diverticular pelvic mass.
2. Multiple intraabdominal abscesses involving the pelvis on both sides, the left gutter and several loops of terminal ileum.
PROCEDURES PERFORMED:
1. Exploratory laparotomy with sigmoid proctocolectomy and low pelvic anastomosis.
2. Diverting loop ileostomy.
3. Partial small bowel resection.
4. Bilateral subfascial blocks to the abdominal wall for local pain control.
ESTIMATED BLOOD LOSS: 500 mL.
COMPLICATIONS: None apparent.
SPECIMENS:
1. Rectosigmoid colon and abscess walls, which may involve adnexa and possibly the right ovary.
2. A 10 cm segment of terminal ileum.
INDICATION FOR PROCEDURE: The patient is a very pleasant 69-year-old female who over 2 weeks ago was diagnosed with perforated sigmoid colon diverticulitis. Initially, the patient was admitted to the hospital, treated with intravenous antibiotics, and eventually discharged to home on oral antibiotics. Unfortunately, a week after the initial event, the patient consulted with an emergency department, freestanding, where she was identified to have a very large fluid collection in her pelvis as well as multiple other fluid collections around the area of the diverticulitis. She was readmitted to the hospital. The largest fluid collection was drained percutaneously by interventional radiology and has been draining copious amounts of purulent exudate since. Unfortunately, the patient's clinical condition did not improve at all. She was never able to tolerate a diet well, she started having episodes of profuse diarrhea and eventually since she did not have any clinical improvement, she was recommended to consider an abdominal exploration with a possible sigmoid proctocolectomy and all other indicated procedures. I discussed with her extensively the benefits and risks of the procedures including the possibility that she may require at least a temporary ostomy to protect her anastomosis and she granted consent.
PROCEDURE PERFORMED AS FOLLOWS: After informed consent was obtained from the patient, the patient was taken to the operating room. She was placed on the operating table in the supine position and general anesthesia was induced. After induction of the general anesthesia, the patient's abdomen, perineum, and perianal areas were then prepped and draped in the usual sterile fashion. Using #10 scalpel blade, an infraumbilical incision was made. Incision was then carried through the subcutaneous tissue with the electrocautery and all the way down to the fascia. The fascia was then divided as well as the peritoneum and access to the peritoneal cavity was obtained. Upon accessing the peritoneal cavity, a large amount of purulent peritoneal fluid was drained out. We opened up the fascia and a very large diverticular mass was palpated down at the pelvis. The mass was so large that we had to enlarge the incision to obtain better access to it. Once the incision had been enlarged, we noticed that there were several loops of small bowel attached to the patient's pelvis with a very thick chronic abscess wall very carefully, using the Metzenbaum scissors. Several of those loops were removed from the patient's pelvis, draining copious amounts of purulent exudate with a reattempt. Once the entire small bowel had been separated from the pelvis from the patient's pelvis, we noticed that at least one of the multiple abscesses contained part of the fimbria of the left tube. This abscess cavity was then excised with the LigaSure device as well as the part of the two. We then proceeded and tried to mobilize the very large diverticular mass from the patient's pelvis, freeing up a large amount of purulent fluid from both sides of the pelvis and from the left gutter. Eventually after a very tedious dissection, we were able to separate this diverticular mass from the patient's urinary bladder and obtained better access to the patient's pelvis. The left colon was then mobilized medially along the white line of Toldt and all the way up to just below the splenic flexure. Once the mobilization had been completed, a Bookwalter retractor was set in place. Using a Glassman clamp to control the descending colon and a Kocher clamp to control the distal aspect of the descending colon, the colon was divided. The LigaSure device was then used to excise this very large diverticular mass from the patient's pelvis all the way down to the peritoneal reflection right at the peritoneal reflection. The patient's rectum was skeletonized. She still had a large amount of inflammation around this area and right at the peritoneal reflection, a 55 mm contour device was used to divide the rectum. Rectum was divided and a colon was sent away for pathologic examination. There was still large amount of necrotic material towards the right aspect of the patient's pelvis, which appeared to possibly involve the right ovary. Using the LigaSure device, this was divided. During the process of the dissection, the left ureter was visualized proximally and followed down falling all the way down into the pelvis. We stayed away from its position at the pelvis, even though there was a lot of desmoplastic reaction from the scarring. On the contralateral side, we did not have to dig down to the patient's retroperitoneum. The appendix on the cecum appeared to be normal. Some of the loops of the distal ileum, which had been attached to the abscesses were partially deserosalized, but not perforated. Once we completed with our surgical excision, we then proceeded to create a pursestring on the descending colon. It appeared that we had enough descending colon for an end-to-end transanal anastomosis. A 29 mm anvil was then placed proximally and we proceeded to create an end-to-end transanal procto-colostomy anastomosis. Unfortunately, right at the site of the anastomosis, the patient still has a lot of inflammation and therefore, the anterior aspect of the wall of the rectum had a tear which was repaired with interrupted 3-0 silk Lembert sutures. I decided to put 19-French round Blake drain down into the patient's pelvis and greater omentum was rotated to pack the pelvis over the drain. The abdominal cavity was then irrigated profusely. There was excellent hemostasis of the colonic mesentery. The nasogastric tube was verified to be in the stomach. At the area of deserosalized terminal ileum, we decided to excise it since it was very inflamed and used this area for a diverting ileostomy. Using 55 mm GIA staplers, the terminal ileum was divided proximally and distally. The mesentery was then taken down with the LigaSure device. Using 3-0 silk interrupted sutures, we connected the two loops, the proximal and the distal loop, and a site for a diverting ileostomy was selected towards the right lower quadrant. Using the Mayo scissors, an ileostomy incision was made. All the fat around it was cored out and once the fascia was reached, a cruciate incision was made on the anterior rectus sheath and the posterior rectus sheath. The two loops of small bowel were then brought out through this incision and secured to the fascia using interrupted 3-0 silk sutures. Once the position of the nasogastric tube had been verified, the fascia was then closed using #1 PDS suture from above and below. Bilateral subfascial blocks using Exparel and 0.25% Marcaine with epinephrine were then applied to the abdominal wall for local pain control and the midline incision was closed at the skin using surgical staples. A Prevena dressing was then applied to this wound. The two loops of ileum were then opened up at the staple line and there were matured as a double barrel diverting ileostomy using 3-0 Vicryl sutures in a Brooke fashion. An ileostomy wafer as well as a bag were applied. The patient has tolerated the procedure very well and has been transferred to the recovery room in stable condition. She made very little urine despite the fact that she was given a large amount of intravenous fluids and it is likely that she still will require some further fluid resuscitation afterwards. A surgical team will continue to follow up the patient as she is hospitalized until she recovers her bowel function and tolerates a regular diet and is ready for discharge to home.
POSTOPERATIVE DIAGNOSES:
1. Perforated diverticulitis with large diverticular pelvic mass.
2. Multiple intraabdominal abscesses involving the pelvis on both sides, the left gutter and several loops of terminal ileum.
PROCEDURES PERFORMED:
1. Exploratory laparotomy with sigmoid proctocolectomy and low pelvic anastomosis.
2. Diverting loop ileostomy.
3. Partial small bowel resection.
4. Bilateral subfascial blocks to the abdominal wall for local pain control.
ESTIMATED BLOOD LOSS: 500 mL.
COMPLICATIONS: None apparent.
SPECIMENS:
1. Rectosigmoid colon and abscess walls, which may involve adnexa and possibly the right ovary.
2. A 10 cm segment of terminal ileum.
INDICATION FOR PROCEDURE: The patient is a very pleasant 69-year-old female who over 2 weeks ago was diagnosed with perforated sigmoid colon diverticulitis. Initially, the patient was admitted to the hospital, treated with intravenous antibiotics, and eventually discharged to home on oral antibiotics. Unfortunately, a week after the initial event, the patient consulted with an emergency department, freestanding, where she was identified to have a very large fluid collection in her pelvis as well as multiple other fluid collections around the area of the diverticulitis. She was readmitted to the hospital. The largest fluid collection was drained percutaneously by interventional radiology and has been draining copious amounts of purulent exudate since. Unfortunately, the patient's clinical condition did not improve at all. She was never able to tolerate a diet well, she started having episodes of profuse diarrhea and eventually since she did not have any clinical improvement, she was recommended to consider an abdominal exploration with a possible sigmoid proctocolectomy and all other indicated procedures. I discussed with her extensively the benefits and risks of the procedures including the possibility that she may require at least a temporary ostomy to protect her anastomosis and she granted consent.
PROCEDURE PERFORMED AS FOLLOWS: After informed consent was obtained from the patient, the patient was taken to the operating room. She was placed on the operating table in the supine position and general anesthesia was induced. After induction of the general anesthesia, the patient's abdomen, perineum, and perianal areas were then prepped and draped in the usual sterile fashion. Using #10 scalpel blade, an infraumbilical incision was made. Incision was then carried through the subcutaneous tissue with the electrocautery and all the way down to the fascia. The fascia was then divided as well as the peritoneum and access to the peritoneal cavity was obtained. Upon accessing the peritoneal cavity, a large amount of purulent peritoneal fluid was drained out. We opened up the fascia and a very large diverticular mass was palpated down at the pelvis. The mass was so large that we had to enlarge the incision to obtain better access to it. Once the incision had been enlarged, we noticed that there were several loops of small bowel attached to the patient's pelvis with a very thick chronic abscess wall very carefully, using the Metzenbaum scissors. Several of those loops were removed from the patient's pelvis, draining copious amounts of purulent exudate with a reattempt. Once the entire small bowel had been separated from the pelvis from the patient's pelvis, we noticed that at least one of the multiple abscesses contained part of the fimbria of the left tube. This abscess cavity was then excised with the LigaSure device as well as the part of the two. We then proceeded and tried to mobilize the very large diverticular mass from the patient's pelvis, freeing up a large amount of purulent fluid from both sides of the pelvis and from the left gutter. Eventually after a very tedious dissection, we were able to separate this diverticular mass from the patient's urinary bladder and obtained better access to the patient's pelvis. The left colon was then mobilized medially along the white line of Toldt and all the way up to just below the splenic flexure. Once the mobilization had been completed, a Bookwalter retractor was set in place. Using a Glassman clamp to control the descending colon and a Kocher clamp to control the distal aspect of the descending colon, the colon was divided. The LigaSure device was then used to excise this very large diverticular mass from the patient's pelvis all the way down to the peritoneal reflection right at the peritoneal reflection. The patient's rectum was skeletonized. She still had a large amount of inflammation around this area and right at the peritoneal reflection, a 55 mm contour device was used to divide the rectum. Rectum was divided and a colon was sent away for pathologic examination. There was still large amount of necrotic material towards the right aspect of the patient's pelvis, which appeared to possibly involve the right ovary. Using the LigaSure device, this was divided. During the process of the dissection, the left ureter was visualized proximally and followed down falling all the way down into the pelvis. We stayed away from its position at the pelvis, even though there was a lot of desmoplastic reaction from the scarring. On the contralateral side, we did not have to dig down to the patient's retroperitoneum. The appendix on the cecum appeared to be normal. Some of the loops of the distal ileum, which had been attached to the abscesses were partially deserosalized, but not perforated. Once we completed with our surgical excision, we then proceeded to create a pursestring on the descending colon. It appeared that we had enough descending colon for an end-to-end transanal anastomosis. A 29 mm anvil was then placed proximally and we proceeded to create an end-to-end transanal procto-colostomy anastomosis. Unfortunately, right at the site of the anastomosis, the patient still has a lot of inflammation and therefore, the anterior aspect of the wall of the rectum had a tear which was repaired with interrupted 3-0 silk Lembert sutures. I decided to put 19-French round Blake drain down into the patient's pelvis and greater omentum was rotated to pack the pelvis over the drain. The abdominal cavity was then irrigated profusely. There was excellent hemostasis of the colonic mesentery. The nasogastric tube was verified to be in the stomach. At the area of deserosalized terminal ileum, we decided to excise it since it was very inflamed and used this area for a diverting ileostomy. Using 55 mm GIA staplers, the terminal ileum was divided proximally and distally. The mesentery was then taken down with the LigaSure device. Using 3-0 silk interrupted sutures, we connected the two loops, the proximal and the distal loop, and a site for a diverting ileostomy was selected towards the right lower quadrant. Using the Mayo scissors, an ileostomy incision was made. All the fat around it was cored out and once the fascia was reached, a cruciate incision was made on the anterior rectus sheath and the posterior rectus sheath. The two loops of small bowel were then brought out through this incision and secured to the fascia using interrupted 3-0 silk sutures. Once the position of the nasogastric tube had been verified, the fascia was then closed using #1 PDS suture from above and below. Bilateral subfascial blocks using Exparel and 0.25% Marcaine with epinephrine were then applied to the abdominal wall for local pain control and the midline incision was closed at the skin using surgical staples. A Prevena dressing was then applied to this wound. The two loops of ileum were then opened up at the staple line and there were matured as a double barrel diverting ileostomy using 3-0 Vicryl sutures in a Brooke fashion. An ileostomy wafer as well as a bag were applied. The patient has tolerated the procedure very well and has been transferred to the recovery room in stable condition. She made very little urine despite the fact that she was given a large amount of intravenous fluids and it is likely that she still will require some further fluid resuscitation afterwards. A surgical team will continue to follow up the patient as she is hospitalized until she recovers her bowel function and tolerates a regular diet and is ready for discharge to home.
